Righting the Ship: Reinvigoration of Shared Governance at the Unit Level

After a series of tumultuous leadership changes left a critical care team in a state of defeated disengagement, team members would need a major turn to chart a successful course for themselves and those entrusted to their care. Through successful implementation of a multi-faceted plan, the team established a successful culture of shared governance. The empowering effects of shared governance enabled this team of critical care nurses to swiftly achieve significant clinical outcome goals while simultaneously preparing them for the unforeseen pandemic.

Empowerment journey

Shared governance is foundational to the nurse empowerment that supports a clinical culture of inquiry and autonomous practice. Effective and successful shared governance has been shown to support nurse retention, engagement, interprofessional collaboration and teamwork that enables the provision of safe, high-quality patient care. In alignment with the trifecta decline of nurse engagement, quality outcomes performance and recruitment/retention, the former unit-based council (UBC) within this challenged critical care unit had dwindling partipation and rarely met.

To foster the redevelopment of a successful and stable foundation, the leadership team prioritized the development of trusting relationships within all levels of this critical care team. Through the provision of authentic servant leadership, successful and trusting relationships were forged. Skilled and two-way communication, combined with empathy and compassion, enabled the leaders of this team to right the ship.

In alignment with evidence supporting the idea that successful shared governance originates from the unit level, rebuilding the UBC was identified as the most logical starting point to rehabilitate this critical care unit. Paramount to the re-establishment of a robust and exhilarating UBC was the recruitment of UBC leaders. Fortunately, in the summer of 2019 a newly implemented leadership team within this critical care unit was able to identify UBC leaders. These leaders encompassed the abilities to inspire and influence their team, fostering the healing and trust-building processes needed to transform this emotionally distressed team.

Through a variety of efforts—spawned through a collaborative effort between the new leadership team and UBC council—leaders were able to capture the hearts and minds of the critical care nurses to drive the nursing practice outcomes. Through shared decision-making, the leadership team and clinical team identified an initiative to align with the unit’s area of greatest opportunity for quality improvement. In 2018, this unit had experienced 18 central line-associated blood stream infections (CLASBI), an unprecedented number. Preventing these infections was the most obvious quality improvement opportunity.

Working with the medical director of critical care and infection prevention, the nursing leadership and UBC team identified an evidence-based approach to mitigate the specific risks identified through a comprehensive root cause analysis performed on each CLABSI case. Once the related outcomes data was analyzed, an interprofessional task force including front-line nurses was developed and deployed. After a thorough appraisal of the internal and external evidence, the task force developed an evidence-based central line care protocol. As the engagement of the clinical staff continued to rise as a result of the trusting relationships that the UBC/leadership collaboration were fostering, the unit’s front-line nurses enthusiastically led educational efforts to implement the new care bundle and perform skills labs. This education enabled validation of the entire staff via return demonstration of proper assessment, care, dressing changes and required documentation. Through this approach, this team of front-line critical care nurses was able to radically reduce the central line infection rate from 18 in 2018 down to just three in 2019.

Back on course

After this dramatic achievement, the embers of excitement began to ignite for continued UBC efforts to drive quality outcomes under the reinvigorated shared governance model at the unit level.

In addition, an interprofessional collaboration began with the unit’s educator, UBC and the newly engaged nurse champions to assess how the bedside nurses could continue to make a direct impact to drive improvement in the unit’s other quality measures.

These nurse champions worked in partnership and collaboration with the unit educator with unwavering support from leadership to hold a hospital-acquired infection boot camp. The critical care unit’s front-line nurse champions presented education and training to the hospital’s medical-surgical and cardiac ICU nursing teams, covering prevention measures for CLASBI, catheter-associated urinary tract infection and ventilator-associated pneumonia prevention measures. The front-line nurses held sessions using return demonstration on proper assessment, care and practices for central lines, catheters and mouth care.

Engagement continued to climb, fostering a spirit of inquiry. UBC members, utilizing an evidenced-based literature search, sought to identify ways of reducing moral distress in a manner that would enhance teamwork and reliance. These critical nurses work in a high-acuity academic Level 1 trauma center which serves as major transfer center for the state of New Jersey. They are accustomed to caring for the sickest patients and can often experience burnout.

After appraisal of the evidence, front-line nurses proposed the implementation of the Code Lavender Project, modeled after a best practice intervention to reduce moral distress through staff-mediated peer acknowledgement. The program includes the provision of individual care packages, including items such as tea, aromatherapy, snacks and an inspirational card signed by the clinical team. The staff shared that Code Lavender provides a process for the interprofessional team members to support the emotional well-being of their peers while contributing to a healthy work environment. This is just one recent example of how the UBC efforts have contributed to establishing and sustaining a healthy work environment. Through these successful efforts, this critical care team has worked in close collaboration with the leadership and medical staff to improve staff engagement, retention and successful collaborations resulting in safe and high-quality care.

The recent pandemic has challenged our health care professionals in an unprecedented manner. Fortunately for this critical care team, they had the serendipitous foresight to focus their efforts on the development and implementation of their UBC. Through the establishment of shared governance, these critical care nurses were able to heal and flourish into a team of miraculous warriors. These fearless warriors battled the effects of the COVID-19 virus in a manner achieving remarkable outcomes for many critically ill patients. The outcomes achieved throughout this pandemic would have been unfathomable to the critical care team prior to establishment of effective shared governance.

On the horizon

As a result of supportive, authentic formal and informal leadership, critical care unit staff who felt powerless and undervalued have become an effective team, passionate about improving quality and safety. The team’s efforts resulted in its ability to provide compassionate, evidence-based, high-quality care to every patient entrusted to the unit. This example has inspired other units throughout the organization to develop successful shared governance models, creating meaningful improvements for staff and patients.

About the Authors

Barbara Cottrell, MBA, BSN, RN, CNML, is clinical director, critical care services at Cooper University Hospital, Camden, N.J.

Shannon Patel, DNP, APN,, NEA-BC, is assistant vice president nursing quality, practice and Innovation at Cooper University Hospital, Camden, N.J.